The present invention relates generally to a method and apparatus for electronic coding of medical services rendered to patients and particularly to a method of coding medical services rendered to patients for compliance with Federal and State statutory and regulatory requirements for the avoidance of fraud and abuse in application for reimbursement from governmental agencies for services rendered pursuant to regulations including Health Care Financing, Medicare and Department of Health and Human Services regulations.
Medical providers are eligible for the receipt of payments from governmental agencies upon providing certain care. Providers are required by statute and regulation to meet particular standards, in reporting and requesting payment, for the purpose of avoiding the commitment of fraud and abuse in requesting and receiving such payment. The provider must properly and correctly code multiple aspects of an encounter with a patient to form the basis for meeting regulatory requirements required for payment. Incorrect coding may likely result in noncompliance with laws or regulations such as the Federal False Claims Act (31 USC 3729), the Health Insurance Portability and Accountability Act (HIPAA), Stark I and II and similar Federal and State laws enacted to protect against fraudulent claims for reimbursement for the providing of health care. Medical providers are thus exposed to criminal and civil penalties relating to compliance with regulatory and statutory requirements.
The medical encounter documentation and coding is increasingly complex. Health Care Financing and Medicare rules require documentation of multiple items for every patient seen. For example, there are likely at least 20 items to be documented for each patient encounter and now, for some care, more than 85 items to be documented.. It is ever more difficult for the provider to remember all of the necessary individual documentation items and to document them appropriately. Increases in staffing has been recommended as a means of addressing the burden of correct coding to insure the submission of reimbursement requests which comply with regulatory requirements. However, steps directed to accurate pre-billing audits have left the human element in place and leaving the provider with the difficult burden of correctly and accurately recalling and interrelating each item required to be documented for each patient. The provider is required to expend additional time, remain exposed to the hazard of forgetting an item for the patient and being subjected to civil and criminal sanctions as well as experiencing the increased cost associated with the pre-audit process.
Due to the complexity of, potential for error in Evaluation and Management Coding (EandM coding) and the potential severity of penalty for noncompliance, many providers deliberately under-code patient encounters resulting in a loss of revenue to the provider. Some estimate that as many as 80% of providers under-code from fear of unintentional noncompliance and resulting legal action. Guides exist for use by providers including xe2x80x9cA Blueprint For Documenting Your EandM Servicesxe2x80x9d, Conomikes Medicare Hotline, November 1997, Vol. 7, Number 1 revised 1998 and St. Anthony""s xe2x80x9cGuide to Evaluation and Management Coding and Documentationxe2x80x9d, Third Edition. Disclosures are provided herewith in an Information Disclosure Statement in accordance with 37 CFR 1.97.
The preferred embodiment of the invention provides a method and apparatus to maximize efficiency and accuracy for the provider in determining and documenting correct Evaluation and Management CPT code(EandM code or EandM coding) as required for agency reimbursement for health care delivered. Evaluation and Management (EandM) services are divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of EandM services. There are two subcategories of office visits including new and established patient and two subcategories of hospital visits including initial and subsequent. The subcategories of EandM services are further classified into levels of EandM services that are identified by specific codes. This classification is important because the nature of physician work varies by type of service, place of service and the patient""s status. The basic format of the levels of EandM services is the same for most categories. First, a unique code number is listed. Second, the place and or type of service is specified, for example, office consultation. Third, the content of the service is defined, for example, comprehensive history and comprehensive examination. Fourth, the nature of the presenting problem(s) usually associated with a given level is described. Fifth, the time typically required to provide the service is specified. The levels of EandM services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision, and similar medical services, such as the determination of the need and or location for appropriate care. Medical screening includes the history, examination, and medical decision-making required to determine the need and or location for appropriate care and treatment of the patient. The levels of EandM services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of EandM services may be used by all medical care providers for the generation of an EandM code representing the level of EandM services rendered for each patient encounter.
This method and apparatus is directed to an electronic or computer base wherein a computer directed by a computer program performs a complete audit of EandM coding prior to billing thus ensuring compliance with statutory and regulatory requirements. The present invention prompts the provider to acquire and document data specifically required for the medical evaluation and, ultimately, the billing for professional services for each different type of patient encounter. The invention effectuates the provider""s actions necessary to meet audit requirements. The present invention is therefore a highly effective system in effecting the required bilateral interaction of the provider with both the patient and the EandM coding requirements of each specific type of patient encounter.
The preferred embodiment of the present invention is the establishment of a unique electronic exam template for each specific type of EandM service or patient encounter. The unique template prompts the provider in the acquisition of data peculiar to the specific type of patient encounter as dictated both by standards of medical care and as required by statutory and regulatory standards of EandM code requirements for billing and reporting to regulatory agencies. The preferred embodiment of the invention is the method of use of the electronic exam template as the basic user interface component of the system. A template or form, specific to the particular type of patient encounter, is displayed on a computer screen which contains text fields, drop-down lists, check boxes and graphics. An exam builder utility provides the capabilities necessary to define a dynamic rules base necessary to automatically code the correct EandM code appropriate for the patient encounter. This EandM code is used for billing purposes and directly affects the physician reimbursements from insurance and managed care organizations.
In one embodiment of this invention, the provider, by use of exam builder utility programs, can produce exam templates having characteristics relating to that provider""s specific medical practice or preferences.
An exam template is comprised of a logical related set of systems. These systems are created with the exam builder utility allowing the provider to create a set of questions and response areas to cover a specific subject matter. These systems are then combined into a group and saved as an exam template. A system is a related set of questions covering a given subject area. These questions are created as system items. Each system item has a set of attributes which define the question, the type of data to gather, the placement on the form, whether it is part of a regulatory requirement for billing and reimbursement purposes and other attributes. The provider is prompted by the exam template to acquire data in order to answer the appropriate set of questions and to address the appropriate response areas required by the specific patient circumstance. The answers and responses of the provider create data input which is processed by the computer, responding to the computer program, to produce an EandM code compliant with the regulatory requirements prerequisite to billing for services rendered.
A relational model is used to store the template and item components of the template medical coding system. The system allows for reuse of a system across multiple Exam Templates. It also provides for complete documentation of the encounter with the patient. There is a consistency of questioning across patients. This consistency provides for more audit friendly records in terms of documentation and coding. The primary benefit of this design however lies in its ability to allow for creation of what is herein referred to as a Rules Base. The Rules Base reference is to the audit rules established by statutory and regulatory requirements previously addressed herein.
The EandM coding process consists primarily of counting questions of certain types and following a number of decision trees. The path taken in these decision trees is based on the questions asked and number of questions answered for each types of patient encounter. The problem the provider has is determining what has and has not been covered with the patient. The provider, using the prior art, must determine by hand the results of the exam in terms of how many Rules Based questions have been addressed; the provider must then remember how they play out in terms of the decision trees. The Rules Base concept supported by the template system here disclosed enables, by computer program, the provider to enter data and the computer then to make these required calculations. A separate Rules Base is defined for each separate type of patient encounter. Each patient encounter will require the provider to complete a History Component, a Physical Component and a Medical Decision Component. Each different type of patient encounter will subject the provider to forming data, regarding each of these components, peculiar to the specific type of patient encounter. For example, the following are indicative of the different types of patient encounters: general multi-system examination; cardiovascular examination; ear, nose and throat examination; eye examination; genitourinary examination; hematologic/lymphatic/immunologic examination; musculoskeletal examination, neurological examination; psychiatric examination; respiratory examination; and skin examination. The provider will, by training, undertake certain data gathering for each patient encounter including the taking of the patient""s history, the making of certain measurements, inspections and examinations and the making of certain medical decisions. The provider will order particular tests and will review the results of the tests. The provider may read a report from another provider regarding test results. The provider may perform the test and prepare the report. The Rules Base established by statutory and regulatory requirements subjects the provider to the documentation of the answers, responses, results, and decisions of each phase of the patient encounter leading to the submitting of a bill for the provider""s professional services.
This disclosure requires the provider to enter appropriate date, answer appropriate questions, performs an audit regarding the provider""s having addressed each element of interest in the patient encounter to the statutory and regulatory schemes and concludes with a EandM coding which meets statutory and regulatory requirements. The provider will select a template appropriate to the type of patient encounter, e.g., a genitourinary examination. The provider will address each item attribute for such a patient encounter and will enter the data required for the ultimate EandM code for billing. The data entered by the provider, in the form of the provider""s answer responses to questions presented by each template, is interrogated by the computer program and computer. Those providing such medical services will recognize that the provider""s inquiry and action will differ for each separate type of patient encounter and for each separate patient and patient encounter.
The process described is a change from the current approach of practicing physicians. Instead of using concepts such as problem focused, detailed and comprehensive, the EandM coding is broken down to the individual elements for each patient encounter. Each section of the patient encounter, i.e., History Component, Physical Component and Medical Decision Component, is coded individually by the number of elements or items entered as data entry by the provider. These elements or items are then manipulated by a computer program and computer for auditing, during the patient encounter, and at the end of the patient encounter with an EandM code resulting for use with the regulatory process and billing. The advantage of this invention is that it decreases the chance of entry of data which an auditor would deem illegible or inappropriate thus voiding that entry. The invention also allows the provider to do real time auditing of the EandM coding process. This in turn provides greater consistency and accuracy in EandM coding and enables the provider in approaching the 100% compliance demanded by the current laws. This invention is a significant step in reducing the risk of noncompliance with possible attendant civil and criminal penalties. The invention has also been demonstrated in tests to increase the likelihood of EandM coding at the level representative of the care provided for the patient encounter and hence increase the likelihood of reimbursement at levels appropriate to the patient encounter.
This invention is applicable to the clinic setting, outpatient services, hospital observations, consultations, inpatient services, emergency visits, home visits, and other medical evaluations.